The client arrives in the postanesthesia care unit after a cardiac catheterization to assess the right atrium. Which client data is the nurse's priority to assess perfusion of the affected extremity after the procedure?
1. Checks the left femoral region for bleeding
2. Monitors client vital signs every 15 minutes
3. Applies direct pressure at the client's IV site
4. Palpates the right femoral artery for pulsations
1
1. To access the right heart, the provider passes the catheter through the femoral vein to enter the inferior vena cava and the right atrium; either femoral vein is practical because the veins merge in the peritoneum eventually becoming the inferior vena cava. The client's provider accesses the left femoral vein for the procedure; thus, the nurse assesses the left femoral region for bleeding and compares the left posterior tibial and dorsalis pedis pulses to baseline for early detection of thromboembolic events. Keeping in mind that the affected vessel is a vein, hemorrhaging from the site probably makes the peripheral pulses very weak because the arteries cannot keep up with the excessive venous return (the vessels never fill). The nurse also assesses both extremities for edema because a thrombus forming in the femoral vein impairs venous return of the leg resulting in edema.
2. The nurse measures vital signs every 15 minutes after a cardiac catheterization, but, unless the femoral vein is bleeding, the vital signs provide secondary evidence about the perfusion to the affected extremity.
3. Applying pressure is a nursing intervention and not client data.
4. The nurse palpates the unaffected extremity as a comparison for the affected ex-tremity.
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